CASE STUDY
Mrs A is 78 years old and has dementia of the vascular type;
she came to Aranlaw from hospital where she had been admitted when attempts to
support her to remain in her own home were unsuccessful due to her failing
memory, disorientation and lack of understanding of risks. These problems
caused her to neglect herself and frequently leave her own home and get lost,
often in the middle of the night. One of the things that made her particularly
vulnerable was her tendency to talk to complete strangers, telling them that
she lived alone and where her home was. When Mrs A arrived at Aranlaw she was
very frightened and angry and did not understand why she was not able to remain
in the flat that she had lived in for over 20 years, she was suspicious of
everyone believing that we were all in some way to blame for what was happening
to her. We started to gather as much information as we could about Mrs A’s life
history and significant events. We were given useful information by neighbours,
a friend of many years and Mrs A’s GP who had known her for over 20 years.
The Aranlaw team immediately adopted the helping techniques
recommended for managing behaviours that are the result of the person feeling
uncomfortable and fearful at this stage of the illness. These include ensuring
that staff do not expose the person’s weaknesses, working with all feelings
expressed including anger which can be frequent and sudden in onset, keeping
our distance until invited to get closer, acknowledging and validating feelings
rather than ignoring them or taking things personally. Most importantly we
acknowledged Mrs A’s lifetime of experience as a senior nurse, asking her
opinion on simple issues where we knew she would be able to feel that her input
was valued and helpful. We gave her a key to her own room and encouraged her to
choose what colour she would like it painted and where she would like to hang
her pictures.
Within 4 weeks Mrs A behaviour started to change in a way
that suggested our care strategy was having a positive impact on her and
helping to make her feel more secure and comfortable; she started to confide in
two staff she now trusted, she admitted that she was frightened of not being in
control and of having memory difficulties. Mrs A became increasingly humorous,
wanted to help staff and other residents as much as she could and was engaging
and affectionate towards those staff she trusted. Mrs A no longer seemed
uncomfortable when in the company of residents in Stages 2 and 3 of their
illness instead she tried to help them as she was now feeling
confident that she was respected for her professional skills and
knowledge.
Mrs A has been with us for nearly a year now, she continues
to live her life to the full despite her dementia; she likes to ‘work’ a full
shift with the day staff only taking herself off to bed when the night staff
have arrived and she feels that things are running smoothly, she goes out
regularly for walks with carers and enjoys nothing more than accompanying
Managers when they go to collect prescriptions etc from GP surgeries.
ANATOMY AND PHYSIOLOGY
BRAIN
The cerebral cortex is an extremely
convoluted and complicated structure associated with the "higher"
functions of the mind—thought, reasoning, sensation, and motion. Each
hemisphere of the cerebral cortex contains areas that control certain types of
activity. These areas are referred to as the frontal lobe, parietal lobe, temporal
lobe, and occipital lobe.
· The frontal
lobe, located behind the forehead, is involved with controlling responses to
input from the rest of the central nervous system (brain and spinal cord). It
is responsible for voluntary movement, emotion, planning and execution of
behavior, intellect, memory, speech, and writing.
· The parietal
lobe, located above the ear, receives and interprets sensations of pain
pressure, temperature, touch, size, shape, and body part awareness.
· The temporal
lobe, located behind the ear, is involved in understanding sounds and spoken
words, as well as emotion and memory.
· The occipital
lobe, located at the back of the head, is involved in understanding visual
images and the meaning of the written word.
The hippocampus plays a crucial
role in learning and in processing various forms of information as long-term
memory. Damage to the hippocampus produces global amnesia.
Diagnostic Evaluation:
Various diagnostic tests may be done to determine the cause.
A comprehensive neuropsychiatric evaluation must be completed to make an
accurate diagnosis. Basic laboratory examination, including CBC with
differential, chemistry panel (including blood urea nitrogen, creatinine, and
ammonia), arterial blood gas values, chest x-ray, toxicology screen (comprehensive),
thyroid function tests, and serologic tests for syphilis. Additional
test may include CT scan, MRI, additional blood chemistries (heavy metals,
thiamine, folate, antinuclear antibody, and urinary porphobilinogen), lumbar
puncture, PET/ single photon emission computed tomography scans. Complete
mental status examination. Comprehensive physical examination.
Treatment:
1. Treatment is generally community
focused; the goal of treatment is to maintain the quality of life as long as
possible despite the progressive nature of the disease. Effective treatment is
based on:
· Diagnosis
of primary illness and concurrent psychiatric disorders.
· Assessment
of auditory and visual impairment
· Measurement
of the degree, nature, and progression of cognitive deficits.
· Assessment
of functional capacity and ability for self care
· Family
and social system assessment.
2. Environmental strategies in order
to assist in maintaining the safety and functional abilities of the patient as
long as possible.
Pharmacologic Treatment
Pharmacologic therapy used for the person with DAT is directed
toward the use of anticholinesterase drugs to slow the progression of the
disorder by increasing the relative amount of acetylcholine. Available drugs
include donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon) and
tacrine (Cognex). An NMDA-receptor antagonist memantine (Namenda) may be
provided in an attempt to improve recognition. Other drugs may be used for
behavioral control and symptom reduction.
· Agitation
management: neuroleptic drugs
· Psychosis:
neuroleptic drugs
· Depression:
antidepressants, ECT
Complications:
1. Without accurate diagnosis and
treatment, secondary dementias may become permanent.
2. Falls with serious orthopedic or
cerebral injuries.
3. Self-inflicted injuries
4. Aggression or violence to self,
others, or property.
5. Wandering events, in which the
person can get lost and potentially suffer exposure, hypothermia, injury, and
even death.
6. Serious depression is demonstrated
in caregivers who receive inadequate support.
7. Caregiver stress
and burden may result in patient neglect or abuse.
NURSING
MANAGEMENT
There
will always be a time for medical care for Mrs. A but nursing care should also
come into play for her welfare and being. There are a number of measures to
indicated in regards of the care to Mrs. A such as identifying behaviors and
functional capacity, providing techniques appropriate for the
enhancement of care for Mrs. A., and also establishing a relationship that is
deemed healthy and satisfying. These steps are just a part of the nursing care
to be given to Mrs. A and are to provided holistically to ensure the paradigms
of nursing such as nursing, health, person, and environment are relevant. It is
in our job description to deliver the best possible care and attention to Mrs.
A and for that every little details of her health is important.
It
is always better to assess her overall condition before any interventions are
to be considered. Always inspect her room when entering as to assess if there
are any improvements or decline to her behavior. If her room seems disorganized
and untidy then there is a possibility that her forgetfulness and wandering
behavior is getting worse therefore certain measures has to implemented. If
ever her room is tidy and organized then these are signs that her condition is
either improving or unforeseen circumstances happened so it is always good to
check up with any patients who are having dementia. Her appearance is also
vital to assess for any changes in her ADL routine like if she is either
well-groomed or not and make the appropriate teachings and discuss possible
ways for her to live comfortably and hygienic such as daily baths, brushing her
teeth slowly and gently, and wearing clean clothes. When interacting
with dementia patients such as Mrs. A it is best to listen to her speech
pattern if there are changes like slurring, incoherence, flight of ideas, loose
association and etc. Assessment should always be the first to identify key
possible problems regarding Mrs. A condition and other interventions will
follow. Taking baseline vital signs everyday is also an essential part towards
the continuation of care for Mrs. A such as pulse rate, respiratory rate, blood
pressure and temperature.
Safety
is also one of the valuable measures to be considered in taking care of Mrs. A
due to a number of reasons such as advanced age and her present disease
condition so it is important to ensure a safe environment. Avoiding over
stimulation of a new environment is a must because too much stimulation of new
objects such as cellphones, computers, or any equipment will make the patient
confused and irritable so therefore a routine schedule should always
be followed when taking care of the patient. Always make sure that she is
wearing the proper paraphernalias and equipment for any emergencies that will
arise like her medic-alert bracelet, locks and wander guards if ever her
condition starts to decline but for Mrs. A it seems like it is going well for
her. Also eliminate any environmental hazards that you may encounter in the
room or in the facility to provide a precautionary measure and to lower the
risks of injury to dementia patients like Mrs. A
It
is always best to not skip the medications as prescribed for Mrs. A because if
there is a delay in her medications her condition will not improve over time.
Medications like Donezepril (Aricept), Rivastigmine (Exelon), and Galantamine
(Razadyne) are just a number of medications that are called cholinesterase
inhibitors that slows or decreases the progress of the disease. If ever there
is a skippage then it is best for the patient to take it the next day but it
should always be avoided so as to not aggravate the condition and progression
of dementia. Lastly nothing is more important than family and visits are
appreciated but not to be frequented due to the possible over stimulation from
the guests. Always integrate community services toward the care to provide the
best possible outcomes with new discoveries and researches that will make a
mark for future treatment of mental disorders like Alzheimers, and Dementia as
well.
Nursing Interventions:
Improving communication
1. Speak slowly and use short, simple
words and phrases.
2. Consistently identify yourself,
and address the person by name at each meeting.
3. Focus on one piece of information
at a time. Review what has been discussed with patient.
4. If patient has vision or hearing
disturbances, have him wear prescription eye glasses and/or hearing device.
5. Keep environment well lit.
6. Use clocks, calendars, and
familiar personal effects in the patient’s view.
7. If patient becomes aggressive,
shift the topic for a safer, more familiar one.
Promoting Independence in Self-care
1. Assess and monitor patient’s
ability to perform activities of daily living.
2. Encourage decision making
regarding activities of daily living as much as possible.
3. Monitor food and fluid intake.
4. Weigh patient weekly.
5. Provide food that patient can eat
while moving.
6. Sit with the patient during meals
and assist by cueing.
Ensuring Safety
1. Discuss restriction of driving
when recommended.
2. Assess patient’s home for safety;
remove throw rugs, label rooms, and keep the house well lit.
3. Assess community for safety.
4. Alert neighbors about the
patient’s wandering behavior.
5. Alert police and have current
picture taken
6. Install safety bars in the
bathroom.
7. Encourage physical activity during
day time
Preventing Violence and Aggression
1. Respond calmly and do not raise
your voice.
2. Remove objects that might be used
to harm self or others.
3. Identify stressors that increase
agitation.
4. Distract patient when an upsetting
situation develops
Reaction Paper based on Dementia Case Study
Based on the given Case on Dementia, we can say that the
team at Aranlaw clearly recognized their roles, functions and responsibilities
to their clients. Seemingly simple adjustments in care routines and approaches
can make a significant difference in the experiences of people with
dementia.... By focusing on the person rather than on the disease, nurses
promote comfort and functional autonomy in older adults whose cognitive
impairments have progressed and yet who are very much alive and deserving of
respectful, dignified care.
As per Mr. Jones, back in 1984, he worked in a Nursing home
as an Orderly, while going to college to become an Emergency Medical Technician
(EMT). There were three shifts, and he rotated in all of them based
on openings in his school schedule. On every shift, one of his main
responsibilities was to roll around with a medication cart and assure that all
of the patients took their numerous medications such as Haldol, lithium,
Vellum. Almost every patient was on heavy doses of sedatives, muscle
relaxants, sleeping pills and anti-psychotics. Additionally about 10
out of the 60 on his ward received weekly electro-shock therapy treatments. He
inquired what it was like from several; they all said it made them feel
better. Unlike the case of Mrs. A, they simply managed clients with
dementia, depression, mental problems or no were else to go, with lots of
pharmaceuticals and little else for the remainder of their lives. This
meant the Nursing home could Higher EMTs, nursing aids, and college students
cheaply instead of social workers, psychologist, nurses, occupational and
physical therapist, mental health counselors, etc. In short the
company made money and the pills kept everyone calm and quite with minimal
staff, intervention and funding resulting in larger profit margins for the
nursing home owner(s). ‘The behavioral management used by the staff at Aranlaw,
seems far more humane than that received by the patients were Aaron
worked. Behavioral management seems much more preferable than
management by medication.
A calm, predictable environment helps people with dementia
interpret their surroundings and activities. Environmental stimuli are limited,
and a regular routine is established. A quiet, pleasant manner of speaking,
clear and simple explanations, and use of memory aids and cues help minimize
confusion and disorientation and give patients a sense of security. Prominently
displayed personal pictures along with clocks and calendars may enhance
orientation to time. By giving MrsA key to her on room and allowing her to
choose what color her room was painted the Aranlaw team is helping to reinforce
feelings of contentment, integrity security, independence, safety and self
–direction which are important for all adults. This is especially true for
people like Mrs A, who are in Erik Erikson's 8th stage, later adulthood
(age 60 years and older); “Ego Integrity vs. Despair”. Additionally since the
color chose was hers it will make it easier for her to remember and to locate
her room. By encouraging active participation from Mrs. A in her personal life,
along with participation in physical activity communication in the daily
nursing activities of the nursing home, the Aranlaw team is helping Mrs A to
maintain cognitive, functional, and social interaction abilities for a longer
period. Within 4 weeks of staying in Aranlaw, MrsA, appears to be in the early
phase of dementia, as she is still a highly productive member of the nursing
home. Fortunately for Mrs A, minimal cuing and guidance may be all
that are needed for her to function fairly independently for a number of years
to come, because dementia of any type is degenerative and progressive, patients
display a decline in cognitive function over time.
After nearly a year of Mrs A staying in the safe and caring
environment provided by the Aranlaw team. Her cognitive, functional, and
behavioral skills improved. This safe home and hospital environment allowsMrs A
to move freely as possible and relieves the family of constant worry about
safety. Mrs A is currently functioning well, and living a productive life
because of the interventions of this forward thinking team. However, as Mrs A’s
cognitive ability declines in the future, the Aranlaw team will need to provide
more and more assistance and supervision in order for her to continue living a
full and functional life as possible.
